With limited time and no prior patient relationship, emergency physicians must make quick decisions balancing the provision of sufficient pain management against the potential for abuse and/or misuse. It is sometimes difficult to detect who might be seeking to misuse opioids. In one study, “classic” drug-seeking behaviors were relatively ineffective in identifying high-risk patients.PDMPs have been available for nearly 80 years. The first state PDMP was established in California , followed by Hawaii , Illinois , Idaho , New York , Pennsylvania , Rhode Island , Texas , and Michigan.Early PDMPs were paper-based, record keeping systems used primarily to provide reports to law enforcement.By 1990 electronic key-punch databases enabled easier data dissemination via PDMPs, and pharmacists and clinicians began to use them.In 1996 the pharmaceutical OxyContinTM was introduced; simultaneously, illicit prescription drugs doubled from 1994-1998.In response, Congress signed the Harold Rogers Prescription Monitoring Program grant into law in 2002, providing the first guidelines and funding for states to develop PDMPs.Since then, 49/50 states have now adopted PDMPs.Since the inception of PDMPs, studies have assessed their impact on opioid prescribing and overdoses.Overall, the literature has been mixed. Some studies have found no relationship between PDMP implementation and outcomes; however, most studies evaluated paper- or faxed-based systems, with physicians receiving information days to weeks after the initial request.In one such study, 21% of the PDMPs evaluated were within their first years of operation or had only recently come online.This is significant because in states with new PDMPs,many physicians were not accessing or using data.

This point is exemplified through Virginia’s PDMP, which was established in 2007 and was initially paper based.After moving to electronic and real-time reporting, data requests exponentially increased from 74,342 in 2009 to 433,450 in 2010.Another factor limiting the effectiveness of PDMPs is that each state has different policies and requirements for providers to use them. Few states mandate prescriber use and in those states that do not mandate use,heavy duty propagation trays compliance varies greatly.In this context, it is logical to assume that if prescribers do not access PDMP data, they cannot be effective.A clear factor that leads to variation in observed effectiveness is that PDMPs are not all designed in the same way, particularly when it comes to their accessibility. Most are representative of separate and distinct technological and political environments at the time of their creation.According to the National Alliance for Model State Drug Laws study in late 2012, 38 state PDMPs are operated by a state health agency and six are operated under the aegis of law enforcement agencies.Additionally, 45 states monitor schedule II-IV controlled substances, 34 states grant authority to monitor schedule V substances, and 13 allow additional monitoring of drugs not listed on Drug Enforcement Administration schedules. Moreover, while several states require physicians to access patient PDMP data before prescribing controlled substances, the majority of states allow for voluntary participation among physicians.Finally, 25 states provide unsolicited, automatic reports of suspicious activity directly to law enforcement but only three automatically send reports to multiple facilities including law enforcement, licensing boards, pharmacies, and prescribers.However, states have looked to update and reformat their PDMPs to better address the opioid crisis. For example, with funding from the Core State Violence and Injury Prevention Program, Oregon reformatted its PDMP to provide more appropriate data to its EPs.

Under this new funding, PDMPs were designed to track schedule II-VI drugs prescribed within Oregon as well as providing physicians with access to the PDMP data of bordering states.Furthermore, pharmacies within Oregon were required to report prescription data within 72 hours of opioid dispensing.Since implementation, Oregon has reported a 38% decrease in the rate of prescription opioid overdose as well as a 58% reduction in deaths related to methadone use.As sharing hubs such as those in Oregon, Michigan, Indiana and Ohio are established, EPs may be better equipped to successfully identify drug-seeking behavior. PDMP design also leads to great variation in usability. For example, some information displayed is not always relevant or organized in a way that allows for EPs to answer specific clinical questions that fit into ED workflow. In some systems, frequent extraneous information is obtained simultaneously.Excessive data forces providers to search for relevant information, squandering valuable time. Furthermore, clinician training on how to use and interpret PDMPs is often limited. Users are often left wading through mountains of patient data seeking to piece together a complete picture. One study surveyed physicians and nurses from diverse specialties after PDMP use and found that practitioners lacked guidance on data interpretation.In EDs time is a valuable resource and, unfortunately, the complexity of some PDMPs limits their usability. For example, in the current structure, PDMPs have experienced growing compliance issues secondary to their difficulty of use. In certain states, physicians are required to register with their PDMP via a notarized medical license and government identification.Password protocols exacerbate issues with PDMP accessibility. Often physicians are required to meet excessive requirements for password security only to find that within a short time their password has expired and the process starts over. Passwords often cannot match previous entries and involve multiple erroneous key elements to meet required fields.

Working in a fast-paced ED, having to frequently create and update complicated passwords quickly transforms these safeguards into a barrier to use. Finally, not all PDMPs track all schedule drugs. Schedule II drugs such as opioids have largely been the focus of PDMPs, but other drugs categorized in alternative schedules also have the potential for abuse. In 2011, for example, ED visits for benzodiazepine abuse, a schedule IV drug, was nearly equal to visits for opioids.ED records have demonstrated a strong association with benzodiazepine abuse and opioid abuse.Despite this potential for additional abuse, only 34 PDMPs monitor schedule II-V drugs.To address many of the usability limitations with PDMPs in EDs,vertical cannabis we suggest several ways to optimize their implementation.Unsolicited reporting is a powerful tool through which PDMPs can automatically send alerts for drug-seeking behavior meeting a specific threshold to the appropriate authority. Such quantitative thresholds have already been implemented in several states with some success. In Virginia, thresholds for individuals receiving 10 prescriptions from 10 providers or within a six-month period were used.Subsequent periodic analysis of the data for automatic, unsolicited reporting showed a steady decrease in the number of individuals meeting thresholds, correlating to a decrease in likely diversion and abuse.Such automated reporting does come with risk as such policies raise concerns about patients being labeled an addict or postponing necessary treatment.In addition, physicians treating cancer patients or those requiring long-term opioid management have expressed concern for their reputation and licensure.However, in the context of the newly-approved National Quality Forum measures for limiting opioid prescribing, PDMPs can take such measures into consideration and would likely have an inverse effect by ensuring that guidelines are followed and patients are treated safely.Data analytics and data visualization may be ways to help contextualize opioid prescriptions for the busy EP. For example, by linking prescriptions to a particular diagnosis physicians may greatly reduce the guesswork involved for prescription behavior. At a glance, a patient with multiple prescriptions for both short and long-acting, opioid pain medications may appear to be an opioid abuser. However, by tethering an explanatory diagnosis to such prescriptions, after investigation this patient could be found to have an extensive chronic pain condition warranting multiple prescriptions. Therefore, fewer mental resources may be required to rule out opioid abuse, reducing the potential for misinterpreting data and in turn provide quicker and better informed emergency care. Painful conditions make up 42% of all emergency department visits.With the increasing focus on analgesia by The Joint Commission’s pain management standards and emphasis on analgesia in patient satisfaction surveys, it is no surprise that medical use of opioids and opioid analgesic prescriptions has been increasing since the early 1990s.Unfortunately, there has also been an increase in prescription opioid abuse and misuse, with a rise in opioid related events including increases in opioid-related ED visits, inpatient hospitalizations, and opioid overdose deaths.Unintentional overdose has now surpassed motor vehicle collisions as the leading cause of injury and death in the United States for adults aged 25–64 years, and the majority of all unintentional poisonings are related to opioids.Not surprisingly, opioid prescribing has come under increasing scrutiny in recent years including in the ED.

The American College of Emergency Physicians Clinical Policy – Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department – states, “Although relieving pain and reducing suffering are primary emergency physician responsibilities, there is a concurrent duty to limit the personal and societal harm that can result from prescription drug misuse and abuse.”While the percentage of U.S. ED visits with opioids prescribed increased from 20.8% to 31.0% between 2001-2010, studies have shown that the majority of opioid prescriptions from the ED are a low pill count and are almost exclusively immediate-release formulations and significantly less likely to be high dose or consist of a large quantity compared to those from office-based practices.Regardless, with a recent study showing that opioid-naive ED patients prescribed opioids for acute pain are at increased risk for additional opioid use at one year, the ED is an important site for the study of opioid-prescribing patterns.Adding to this body of literature, a recent article in the New England Journal of Medicine showed that opioid prescribing habits vary widely between providers in the same ED and patients who receive treatment of “high-intensity” opioid prescribers had higher rates of long-term opioid use.Recent interventions for decreasing opioid prescribing have focused on prescription drug monitoring programs and creation of opioid-prescribing guidelines.Opioid prescribing guidelines have been shown to reduce rates of opioids prescribed for both minor and chronic complaints in acute care settings.Most recommendations on safe opioid prescribing for the ED recommend a maximum of three- to five-day courses of opioid medications.With the increasing prevalence of electronic medical records and electronic order-entry systems has come an increasing interest in the ability to standardize clinical workflows in an effort to reduce medication-related errors.To date, no study has assessed the effect of default tablet quantities as part of electronic order entry on emergency physicians’ prescribing patterns. Our primary objective was to evaluate opioid-prescribing patterns before and after removal of the default quantity of 20 tablets for opioid prescriptions in the EMR.Our primary objective was to evaluate opioid-prescribing patterns after removal of default quantity of 20 tablets in the EMR. When the default quantity was in place, the majority of prescriptions provided were for this exact quantity , suggesting that prescribing behavior is strongly influenced by a default quantity prepopulated in the EMR. After removing the default, the number of prescriptions provided for this quantity decreased, and the median number of tablets prescribed with each prescription had a statistically significant reduction. Removing the default quantity requires that physicians choose the number of tablets they will prescribe. Had our primary objective been to achieve a more significant reduction in quantity provided, we could have changed to a smaller default value of 10 or 12 tablets and evaluated the impact of this change. However, the increased variation of tablet quantity prescriptions observed after removal of the default may reflect more appropriate prescribing patterns—a smaller quantity of analgesia tablets needed for less severe pain or pain expected to resolve quickly and greater quantities for more severe pain or pain expected to be prolonged. In many clinical scenarios it may be beneficial to avoid variation among practicing clinicians in a single ED, such as in the treatment of an acute myocardial infarction or sepsis. Having a default opioid quantity in the EMR, while demonstrated to successfully reduce variation in clinical practice patterns, may not be optimal for patient care. This would reflect a case where variation of prescribing patterns may be more appropriate than standardization. A “one-size-fits-all” approach to opioid prescribing and ignoring variable durations and severities of acute pain syndromes will predictably result in undertreatment for some patients and over treatment for others. The total number of prescription for opioids was also noted to have decreased during the study period. In the pre-intervention period, there were 151.6 prescriptions for opioids per 1,000 discharged adult patients compared to 106.69 per 1,000 in the post-intervention period.